The concept of a Patient-Centered Medical Home (PCMH) is receiving increased attention as a potential means to improve care. Payers, purchasers, and policy makers see it as a vehicle for moderating costs and improving quality, in part through revitalizing primary care. Understanding practice transformation in small practices can help us accelerate the adoption of the PCMH, since the vast majority of primary care in this country is provided through small practices, yet most of the research to date on quality improvement has focused on large medical groups. We propose to take advantage of a national list of practices that have demonstrated implementation of PCMH model by achieving recognition through NCQA's Physician Practice Connections(R)--Patient-Centered Medical Home" (PPC(R)-PCMH) program. These standards were developed from research, advisory groups, pilot tests and public comment and are endorsed by the National Quality Forum, numerous physician organizations, and stakeholders as a standardized tool for qualifying practices for PCMH demonstration projects. Over half of the practices that have achieved recognition have fewer than 5 physicians. These small practices are located in 14 different states and vary in size, ownership, and patient populations served. Building on our ongoing collaboration with leading researchers on quality improvement, we will: 1) Detail the transformation process among small physician practices that have successfully implemented the PCMH model (based on achievement of Level 3 PPC-PCMH recognition) and that represent diverse states, organizational characteristics, PCMH demonstration programs, and patient populations;2) Identify organizational and contextual factors that distinguish practices with a higher level of PCMH implementation (based on Level 3 recognition) compared to those with lower levels of implementation (Level 1 or 2) among 300 small practices representing diverse states, organizational characteristics, demonstration programs, and patient populations;3) Compare physician experiences among 300 small practices with higher versus lower levels of PCMH implementation;and 4) Compare operational costs and revenue among 300 small practices with higher versus lower levels of PCMH implementation. We will use case studies of a purposive sample of 10 practices to gather both qualitative and quantitative information on the process of transformation as well as to identify key barriers and supports for change. We will then conduct a national survey of 300 small practices with PPC-PCMH recognition to gain more generalizable knowledge about practice transformation. This study will provide an unprecedented look at the factors that support PCMH implementation in small practices, and will allow us to identify the types of supports that are critical to successful PCMH implementation as well as the impact on practice costs/revenues and physician work experiences. With NCQA's strong ties to multiple stakeholders, we have a unique opportunity to disseminate these findings to a national audience and to use the results to inform our programs. PUBLIC HEALTH RELEVANCE: Payers, purchasers, and policy makers see the Patient-Centered Medical Home as a vehicle for moderating costs and improving quality, in part through revitalizing primary care. This study pairs 10 case studies with a national survey of 300 small practices that have implemented the medical home to explore the transformation process. This study will provide an unprecedented look at the factors that support PCMH implementation in small practices, and it will allow us to identify the types of financial and other supports that are critical to successful PCMH implementation as well as the relationship of PCMH implementation to practice costs/revenues and physician work experiences.